Study Sheds Light on Common Cause of Back Pain

Unexplained low back pain is incredibly common, affecting about 80% of adults at some point during their lifetimes. In the last three months, more than one-quarter of U.S. adults report that they’ve experienced low back pain, which is the most common cause of job-related disability, according to the U.S. National Institute of Neurological Disorders and Stroke (NINDS).¹

The direct and indirect costs associated with low back pain are immense, reaching $90 billion a year in the U.S. alone.² In most cases, low back pain resolves on its own in a few days or weeks, but sometimes it persists for 12 weeks or more, at which point it’s considered chronic.

It’s estimated that about 20% of those who start out with acute low back pain end up with chronic low back pain, with symptoms persisting at one year.³

While many cases of acute low back pain are due to sprains and strains caused by lifting something heavy, overstretching or twisting in an improper way, general degeneration of the spine that occurs with age can also be a culprit. Further, researchers from Johns Hopkins noted in the journal Nature Communications that 90% of low back pain is nonspecific, meaning it has no apparent cause.⁴

The researchers noted that even in cases of intervertebral disc degeneration, there may be no symptoms, meaning spinal degeneration isn’t always the reason for low back pain. They suggested instead that an overgrowth of nerves into the cartilaginous endplates in the spine could be to blame for many cases of low back pain, and the study they conducted suggests that they’re right.

‘Swiss Cheese Bones’ Blamed for Low Back Pain

The joints in your spine contain a bony vertebrae, spinal disc and cartilage endplates, which act as cushions for the vertebrae.

In a news release, study author Xu Cao, Ph.D., with the Johns Hopkins Institute for Cell Engineering at the Johns Hopkins University School of Medicine, stated, "The cartilage endplate is the cushion on a seat that makes it more comfortable. But, like similar tissue in knee and hip joints, it succumbs to wear and tear over time.”⁵

The study involved mice aged more than 20 months, which is equivalent to a human age of 70 to 80 years. Samples of the bony end plates were analyzed, revealing that the once-soft cartilaginous tissue had become hard and resembled porous bone with a Swiss-cheese appearance.

In previous research, Cao and colleague revealed that cells called osteoclasts create the “Swiss cheese-like” bony structure where soft, cartilage should be, with the spaces providing room for nerves to penetrate the area. "Cartilage does not typically have nerve and blood vessels. However, when cartilage becomes a porous bony structure with growth of nerve fibers, it could be the source of back pain," Cao said.⁶

In the mice study, osteoclasts and nerve fibers were marked with fluorescent tags, revealing that both could be found near the vertebrae and that osteoclasts could be secreting netrin-1, a signaling molecule, to trigger nerve growth in the area.

The researchers then genetically engineered mice to lack genes for osteoclast formation, and when the mice lacked osteoclasts, they had fewer pain-sensing nerves in the cartilage endplates compared to mice with the osteoclast-forming gene. “These findings suggest that osteoclast-initiated porosity of endplates and sensory innervation are potential therapeutic targets for spinal pain,” the researchers noted.⁷

What Else May Be Causing Your Back Pain?

If you’re experiencing low back pain without an obvious cause, a mechanical cause is likely to blame. Aside from the sprains and strains or intervertebral disc degeneration mentioned earlier, overuse and misuse of the muscles supporting your spine, poor muscle strength and inappropriate posture while sitting, standing and walking are also reasons why you may suffer from lower back pain.

Though it may sound surprising, muscle imbalances can often account for back pain that makes it difficult to perform everyday activities. Your lower back, also called the lumbar region, is a complex structure consisting of vertebra, spinal cord, discs, nerves, ligaments and muscles. Each of these work in concert to achieve pain-free mobility.

Most low back pain occurs in five vertebrae in the lumbar region (L1-L5), which support the weight of your upper body.⁸ When there is an imbalance in any of the musculature supporting your lower back, hips, legs or upper back, it may cause an imbalance in the remainder of the interacting muscles.

For instance, when walking with your toes pointed outward, the muscles in your hips and lower back tighten, increasing your risk for lower back pain. Sitting with your shoulders hunched over a computer screen stretches muscles in your upper back and places added stress on your lower back, increasing your risk for lower back pain.

There’s also some evidence that back pain can be related to negative emotions. The late Dr. John Sarno used mind-body techniques⁹ to treat patients with severe low back pain, as he believed that pain is your brain’s response to unaddressed stress, anger or fear.

In one study that supports the idea that pain can have psychological underpinnings, emotion awareness and expression therapy reduced chronic musculoskeletal pain by at least 30% in two-thirds of patients while one-third of patients improved by 70%.¹⁰

Many Cases of Back Pain Are Mistreated

Many people who see their physician for lower back pain are prescribed opioid painkillers, even though guidelines from the American College of Physicians (ACP) state individuals with lower back pain should first try heat wraps, exercise and other nondrug solutions first, and prescription drugs should only be used as a last resort. Even then, opioids aren’t mentioned among the first-line drug options. According to ACP:¹¹

“Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence).

If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation).”

In fact, this inappropriate treatment approach to back pain is a driving force behind the opioid epidemic, according to Dave Chase, co-founder of Health Rosetta,¹² citing a 2018 JAMA Network Open paper.¹³ The JAMA paper also recommends, “For chronic low back pain, comprehensive care should ideally include exercise, physical therapy, behavioral therapy, and, in some cases, complementary and alternative medicine.”¹⁴

Strengthening and Realigning Your Body Posture for Back Pain

Eric Goodman, a chiropractor and pioneer in the world of structural biomechanics, is the creator of Foundation Training, a highly effective protocol for back pain. Foundation Training focuses on body weight exercises that integrate as many muscles as possible to strengthen and elongate your core and posterior chain — which includes all the muscles that connect to your pelvis — thereby alleviating many chronic pain issues.

Goodman himself once suffered from severe low back pain, and he wasn’t satisfied with his doctors’ conventional approach to treatment — surgery. Instead of surgery, he sought out a long-term solution by studying anatomy, alignment and exercise, which resulted in Foundation Training.

The program trains the muscle chain in your shoulders, back, butt and legs, such that it takes the burden of support away from your joints. Once your large muscle groups are providing the support your body needs, your back pain will likely dissipate.

Goodman’s program is detailed in his book, "True to Form: How to Use Foundation Training for Sustained Pain Relief and Everyday Fitness,”¹⁵ but there are also a number of free videos on his website at FoundationTraining.com. Correcting your posture is also part of the process, and once your muscles become more properly aligned and stabilized, your posture will follow suit.

Compression breathing is another component, which involves re-educating the muscles surrounding your axial skeleton, the spine of your rib cage, teaching them to be in a state of expansion rather than contraction. You'll find a demonstration of this technique in the video below, but here’s a quick summary of the process:

Two-Minute Exercise for Back Pain

In the video at the top of this page, you will find demonstrations of Foundation Training exercises, which incorporate as many muscles into a given movement as possible, dispersing more force throughout your body, taking friction away from your joints and putting that tension into your muscles instead.

In addition to using compression breathing, you’ll want to perform the exercises barefoot and, ideally, walk barefoot as often as you can. With your shoes off, pay attention to pushing your feet into the ground.

Most people have weak feet with poor grip strength. Think of your feet as anchors for your entire body in a sea of gravity. So, push back against gravity. Stand as big, broad and as tall as you can. Try to really grab the ground with your feet by activating your arches, toes and ankles.

According to Goodman, most people will notice a difference in their body within a week or two. Within three weeks, you should notice profound differences, provided you’re doing the exercises five to 10 minutes every single day. You don’t need to worry about recovery here, as you’re not exercising your muscles to failure, where you’re breaking down microfibrils in your muscles that would need time to repair.

It’s recommended that you use a variety of Foundation Training exercises to reinforce proper movement in your body. However, if you’re struggling with back pain, try this two-minute exercise, which is also demonstrated in the featured video. For acute back pain, Goodman recommends doing this exercise as much as 10 to 20 times a day. Hold each position for 10 to 20 seconds.

1. Stand feet shoulder-width apart, facing a chair. Lightly squat, pushing your buttocks back, keeping your back straight. Place the fingertips of your hands on the front edge of seat of the chair.
2. With your knees slightly bent, the weight on your heels, walk your fingertips across the seat, away from you as you push your hips back.
3. Once you’ve reached the limit of your stretch, lift your torso, extending your lower spine, and push your hands out behind you to widen your chest as much as possible. Be sure to squeeze your shoulder blades together.
4. Shift your arms forward, as high as you can overhead, thumbs pointing inward toward each other, while pushing your buttocks out, lengthening through your back. This will intensify the pressure in your back. Engage the hamstrings by lightly squeezing your knees together and straightening your legs ever so slightly.
5. Slowly stand up, lowering your arms as you raise your torso.

Beyond exercise, be sure to look through these additional tips to beat back pain, which include everything from sleep position and vitamins to grounding and massage therapy. For many, a comprehensive plan works best to achieve long-term back pain relief.